British Journal of Anaesthesia 102 (6): 73948 (2009)

doi:10.1093/bja/aep096 Advance Access publication May 6, 2009

REVIEW ARTICLE Failed spinal anaesthesia: mechanisms, management, and prevention

P. D. W. Fettes1*, J.-R. Jansson2 and J. A. W. Wildsmith1
1

University Department of Anaesthesia, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK. 2 AstraZeneca R&D SE-151 85, Sodertalje, Sweden
*Corresponding author. E-mail: paulfettes@nhs.net
Although spinal (subarachnoid or intrathecal) anaesthesia is generally regarded as one of the most reliable types of regional block methods, the possibility of failure has long been recognized. Dealing with a spinal anaesthetic which is in some way inadequate can be very difcult; so, the technique must be performed in a way which minimizes the risk of regional block. Thus, practitioners must be aware of all the possible mechanisms of failure so that, where possible, these mechanisms can be avoided. This review has considered the mechanisms in a sequential way: problems with lumbar puncture; errors in the preparation and injection of solutions; inadequate spreading of drugs through cerebrospinal uid; failure of drug action on nervous tissue; and difculties more related to patient management than the actual block. Techniques for minimizing the possibility of failure are discussed, all of them requiring, in essence, close attention to detail. Options for managing an inadequate block include repeating the injection, manipulation of the patients posture to encourage wider spread of the injected solution, supplementation with local anaesthetic inltration by the surgeon, use of systemic sedation or analgesic drugs, and recourse to general anaesthesia. Follow-up procedures must include full documentation of what happened, the provision of an explanation to the patient and, if indicated by events, detailed investigation. Br J Anaesth 2009; 102: 73948 Keywords: anaesthetic techniques, regional; anaesthetic techniques, spinal; complications

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Two conditions are, therefore, absolutely necessary to produce spinal anesthesia: puncture of the dura mater and subarachnoid injection of an anesthetic agent. Gaston Labat, 1922 Spinal (intrathecal) anaesthesia is generally regarded as one of the most reliable of regional block methods: the needle insertion technique is relatively straightforward, with cerebrospinal uid (CSF) providing both a clear indication of successful needle placement and a medium through which local anaesthetic solution usually spreads readily. However, the possibility of failure has long been recognized, the above quote being taken from the work of Gaston Labat,24 the father of modern regional anaesthesia. His two conditions for success, although perhaps a little simplistic when related to current knowledge, still indicate the essence of the method and provide a starting point for the consideration of failure, although it may be helpful to dene exactly what this means rst. Literally, the word failure implies that a spinal anaesthetic was attempted, but that no block resulted; this happens, but perhaps a

commoner outcome is that a block results, but is inadequate for the proposed surgery. Such inadequacy may relate to three components of the block: the extent, quality, or duration of local anaesthetic action, often with more than one of these being inadequate. This review has considered all three eventualities within the denition of failure. Most experienced practitioners would consider the incidence of failure with spinal anaesthesia to be extremely low, perhaps less than 1%. However, a gure as high as 17% has been quoted from an American teaching hospital, yet most of the failures were judged to be avoidable.28 A survey at another such institution considered that this high rate was unacceptable, and recorded the much lower, but still signicant, gure of 4%, with errors of judgement as the major factor.32 The clear implication is that careful attention to detail is vital, and it has been shown that a failure rate of ,1% is attainable in everyday practice.17 Minimizing the incidence of failure is obviously a pre-requisite for gaining the benets of spinal anaesthesia, and prevention must start with full recognition of the potential pitfalls so that clinical practice can be tailored to their avoidance.

# The Author [2009]. Published by Oxford University Press on behalf of The Board of Directors of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournal.org

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In general terms, block failure is usually ascribed to one of three aspects: clinical technique, inexperience (of the unsupervised trainee especially), and failure to appreciate the need for a meticulous approach.10 However, such broad categories reveal little about the many detailed ways in which an intrathecal injection can go astray within each of the ve phases of an individual spinal anaesthetic, these being, in sequence, lumbar puncture, solution injection, spreading of drug through CSF, drug action on the spinal nerve roots and cord, and subsequent patient management. All of the problems involved are well described in the literature, but usually long ago, and many practitioners seem unaware of the issues involved. For instance, the neuroscience division of AstraZeneca received 562 Product Defect Notication reports in the 6 yr to December 31, 2007, all ascribing failed spinal anaesthetics to ineffective bupivacaine solution (Fig. 1). Nearly one-third of reports (179) were from the UK, but virtually every country where the drug is marketed was represented. However, analysis showed that the returned material was within the products specication in every case so a formal review, based on a literature search, was thought to be worthwhile.

160 140 120

The Americas Europe Asia Australasia

Number of reports

100 80 60 40 20 0 1995 2000 Calendar year 2005

Fig 1 Annual numbers of reports of failed spinal anaesthesia with bupivacaine received by AstraZeneca between January 1, 1993 and December 31, 2008 plotted according to region of the world.

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Search strategy
For this review PubMed and Google databases were searched using the terms failed regional anaesthesia, failed regional anesthesia, failed spinal anaesthesia, and failed spinal anesthesia. Relevant articles were retrieved as were any possibly relevant papers in their reference lists. Supporting searches were performed on subjects that may not have been otherwise identied, specic examples being CSF volume, dural ectasia, and the chemical compatibility of local anaesthetics with adjuncts. In addition, searches were made using Planet (an AstraZeneca internal database), Biosis, Current Contents, Embase, PsycINFO, Medline, and Medline Daily update, using the terms Failed Spinal Anaesthesia and Failed Spinal Anesthesia as sole search terms and spinal anesthesia or spinal anaesthesia or spinal anesthetic or spinal cord anesthesia or spinal cord anaesthesia or anesthesia, spinal or anaesthesia, spinal and treatment failure or therapy failure, and Intrathecal. All papers identied as relevant are included in this review.

tissue or blood clot can easily obstruct the ne bore needles used now. Otherwise, a failed lumbar puncture is virtually always because of either poor positioning of the patient or incorrect needle insertion, both factors being within the control of the anaesthetist. Abnormalities of the spine (kyphosis, scoliosis, calcication of ligaments, consequences of osteoporosis), obesity, and patient anxiety make both positioning the patient and needle insertion more difcult, especially in the elderly. Texts of regional anaesthesia give more extensive instruction than can be provided here, and good clinical training is the key to success, but most difculties are attributable to lack of adherence to the basic rules. Positioning The patient is placed on a rm surface; the lumbar laminae and spines are separated maximally by exing the whole spine (including the neck), the hips, and knees; rotation and lateral curvature of the spine are avoided; these points apply to lumbar puncture in both sitting and lateral horizontal positions; the former is usually an easier option in difcult patients, but sometimes the reverse is true. The role of the assistant in achieving and maintaining the patient in the correct position cannot be underestimated.35 Needle insertion Although its accurate identication can be difcult using clinical land-marks, what is judged to be the third lumbar inter-space is used usually, but examination may indicate that another is preferable. However, care should be taken not to venture too cephalad and risk damage to the spinal cord.33 With the midline approach, insertion should start precisely in the mid-line, mid-way between the posterior spines, with the needle shaft at right angles to the back in both planes. Small, incremental changes in needle angle

Mechanisms and their prevention

Failed lumbar puncture
Inability to obtain CSF, sometimes referred to as a dry tap, is the only cause of failure which is immediately obvious. A needle with a lumen blocked at the outset is a theoretical possibility, but is most unlikely with modern equipment. However, both needle and stylet must be checked for correctness of t before use, and the needle should not be advanced without the stylet in place because

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should be made only if there is resistance to advancement; if resistance is met, cephalad angulation should be tried rst, and such angulation may be appropriate from the start if the patient is unable to ex fully (e.g. the obstetric patient at term). A degree of caudad angulation is sometimes needed, with a slight lateral direction being required very rarely. All authorities recommend that the anaesthetist should have a good knowledge of spinal anatomy and relate these to changes in tissue resistance as the needle is advanced so that a mental picture of where the needle tip lies is appreciated. The above points apply specically to the midline approach; lateral or paramedian approaches are preferred by some,27 especially if the mid-line ligaments are heavily calcied, but they are inherently more complex techniques. However, in the face of difculty, the same basic rules apply: make sure that the patient is in the correct position and that the correct angles and insertion technique are used.

Solution injection errors

The appearance of CSF in the needle hub is an essential pre-requisite for spinal anaesthesia, but it does not guarantee success, which also requires that a fully effective dose is both chosen and actually deposited in the CSF. Dose selection Studies of many factors inuencing intrathecal drug spread have shown that the dose injected, within the range normally used, has only a small effect on the extent of a spinal anaesthetic, but is far more important in determining the quality and duration of block.20 Overall, the actual dose chosen will depend on the specic local anaesthetic used, the baricity of that solution, the patients subsequent posture, the type of block intended, and the anticipated duration of surgery. Thus, knowledge of the factors inuencing intrathecal drug spread and clinical experience with any particular local anaesthetic preparation are important guides to choosing an effective dose. However, the need to guarantee an adequate effect means that the doses of drugs injected in standard single shot techniques are larger than is strictly necessary, experience with dose titration during continuous spinal anaesthesia showing clearly that lower doses are often effective.21 In attempts to either minimize hypotension, for example by attempting to produce a unilateral block, or speed postoperative mobilization, by decreasing duration, some practitioners use lower doses than is traditional3 (e.g. 5 10 rather than 15 mg of hyperbaric bupivacaine). Used correctly, and in appropriate situations, such doses can be reliable, but they do mean that the margin for error is reduced and that the consequences of other problems (e.g. Loss of injectatesee below) will be exaggerated and so risk an inadequate block. It becomes even more important to ensure that the whole of that lower dose reaches the CSF and then spreads properly, remembering that the dead space of the needle will contain a signicant proportion of what is a small volume to start with. Loss of injectate The Luer connection between syringe and needle provides a ready opportunity for leakage of solution. A particular variant of this problem being a leak through a defect at the junction of needle hub and shaft.6 Given the small volumes involved, the loss of even a few drops may cause a signicant decrease in the mass of drug reaching the CSF, and thus in its effectiveness. To avoid this, it has long been conventional teaching that the syringe containing the injectate must be inserted very rmly into the hub of the needle, and that a subsequent check is made that no leakage occurs. Misplaced injection Needle and syringe must be connected rmly, but great care should be taken to avoid either anterior or posterior

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Adjuncts A calm, relaxed patient is more likely to assume and maintain the correct position, so explanation (before and during the procedure) and gentle, unhurried patient handling are vital; light anxiolytic premedication contributes much to relaxing the patient; local anaesthetic inltration at the puncture site must be effective without obscuring the landmarks, but must include both intradermal and s.c. injection. Achieving the correct position is a particular challenge in the patient in pain (e.g. from a fractured hip) and systemic analgesia (i.v. or inhalation) helps considerably. The aim of such adjuncts is to optimize the patients position and to prevent any movement. As will be discussed later, it takes only slight movement to displace the needle from its target. Advances in ultrasound technology are reaching the stage where it can be used to overcome difculties with lumbar puncture, but clinicians will still need to be aware of the problems and how they should be overcome.

Pseudo-successful lumbar puncture The appearance of clear uid at the needle hub is usually the nal conrmation that the subarachnoid space has been entered. Rarely, however, the clear uid is not CSF, but local anaesthetic injected as a top-up for an epidural which then proved inadequate for a Caesarean section, or even spreading there from the lumbar plexus.26 Unfortunately, a positive test for glucose in the uid does not conrm that this uid is denitely CSF because extracellular uid constituents diffuse rapidly into uids injected into the epidural space. Another, even rarer, suggested cause of clear uid appearing at the needle hub, but not conrming successful lumbar puncture, is a congenital arachnoid cyst.39

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displacement of the needle tip from subarachnoid to epidural space, where deposition of a spinal dose of local anaesthetic will have little or no effect. Fluid aspiration, after attachment of the syringe, should conrm free ow of CSF and, thus, that the needle tip is still in the correct space, but such aspiration may displace the tip unless performed carefully, as may the force of the injection of the syringe contents. To prevent displacement at any stage, it has been advocated that the dorsum of one hand should be anchored rmly against the patients back and the ngers used to immobilize the needle, while the other hand is used to manipulate the syringe.40 Most practitioners would recommend aspiration for CSF after the injection to conrm that correct placement is maintained, and some advocate that this is done half way through as well although neither of these practices has been shown to inuence the outcome of the block.32 40 Tip displacement must be guarded against with any type of spinal needle, but it is a particular issue with the pencil point needles now used widely to minimize the incidence of post-dural puncture headache. The opening at the end of these needles is proximal to the tip, so only a minor degree of backward movement during syringe attachment may result in epidural injection as was recognized at an early stage in the widespread use of such needles.12 The distances involved are of the order of a millimetre or two, but (as with leakage) misplacement of only a small amount of solution can have signicant effects. An additional issue with pencil-point needles is that the opening, being much longer than the bevel of a Quincke needle, may straddle the dura so that some solution reaches the CSF, and some the epidural space (Fig. 2).41 This may be exaggerated by the dura acting as a ap valve across the needle opening. Initially, CSF pressure pushes the dura outwards so that aspiration is

successful (Fig. 3A), but subsequent injection pushes the dura forward and the solution is misplaced (Fig. 3B). A variant is that the needle tip penetrates the dura, but it is the arachnoid mater that acts as the ap valve so that a subdural injection results (Fig. 3C). This misplacement is usually thought of as leading to excessive spread during epidural block, but the equivalent phenomenon has been described after intended subarachnoid injection,37 and is a recognized complication of myelography.22 Subdural injection has also been identied as the cause of a failed block when either epidural11 or subarachnoid15 injection was intended. These eventualities, being subtle abnormalities of placement, are impossible to identify at the actual time, but rotation of the needle through 3608 after the initial appearance of CSF, and before check aspiration, has been advocated as a way of minimizing the possibility of them occurring, the theory being that the rotation reduces the risk of the membrane edges catching on the opening.

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Inadequate intrathecal spread

The intrathecal spread of a local anaesthetic solution, even when correctly placed, has truly been described as capricious.7 The factors that affect it are many, but the focus here will be on those that may result in inadequate spread. Anatomical abnormality Intrathecal spread is governed by interplay between solution physical characteristics, gravity, and the conguration of the vertebral canal. Anatomical abnormalities that lead to problems with spread can be both overt and covert. The curves of the vertebral column are integral to solution

Epidural space

Dura and arachnoid CSF

Subarachnoid space

Cauda equina

Epidural space

Dura and arachnoid

Subarachnoid space

Cauda equina

A Aspiration

LA Correct

B Epidural

LA

LA Incorrect

LA
Subdural

LA

Fig 2 Possible positions of the tip of a pencil-point needle. If it is correctly placed (upper picture) all of the local anaesthetic solution will reach the subarachnoid space, but if the opening straddles the dura (lower picture) some solution will be deposited in the epidural space.

Fig 3 To show how the dura or arachnoid mater may act as a ap valve across the opening of a pencil point needle. During aspiration (A) the dura/arachnoid are pulled back allowing CSF to enter the needle. During injection the dura (B) or arachnoid (C) is pushed forward and the local anaesthetic enters the epidural or subdural space.

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spread and any obvious abnormality, kyphosis, or scoliosis, may interfere with the process. Examination of the patient should reveal whether this might occur, but it is not possible to predict whether the effect will be excessive spread or failure. A very rare possibility, which is not apparent on examination, is that the ligaments that support the spinal cord within the theca form complete septae and act as longitudinal or transverse barriers to local anaesthetic spread. This can result in a block that is entirely unilateral2 or of insufcient cephalad spread. Spinal stenosis or other pathological lesions might also limit spread, effectiveness, or both, one such case being attributed to the consequences of previous intrathecal chemotherapy.1 42 Similarly, previous surgery within the vertebral canal may result in adhesions that interfere with spread. An interesting abnormality considered to have caused restricted spread in a single patient was a larger than usual volume of CSF in the lumbar theca.18 Subsequent systematic study has shown that lumbar CSF volume is the most important factor inuencing the variability seen between individuals in the spread of an intrathecal injection.9 A negative correlation was found between lumbar CSF volume and the peak sensory level achieved with hyperbaric bupivacaine when the injection was performed in both supine and sitting positions. A variation of this factor is dural ectasia, which is a pathological enlargement of the dura seen in the majority of patients with Marfans syndrome and in some other connective tissue disorders.25 Solution density Consistently effective spinal anaesthesia requires that the practitioner has a good understanding of the factors that affect intrathecal spread, particularly, but not only, solution density. A solution with a density within the normal range of that of CSF (isobaric) will virtually guarantee block of the lower limbs with little risk of thoracic nerve block and thus hypotension.43 However, plain solutions of bupivacaine, although often referred to as isobaric, are actually of sufciently lower density to be hypobaric, especially at body temperature. As a result their range of spread is much less predictable than that of a truly isobaric preparation, and occasionally the block may be no higher than the rst, or even second, lumbar dermatome when administered to the non-pregnant supine patient.29 Although the impact of variations in CSF volume has yet to be studied with these solutions, it seems likely that this factor may well be a factor in their variability. Solutions with a density greater than that of CSF (hyperbaric) move very denitively under the combined inuence of gravity and the curves of the vertebral canal. Over a hundred years ago, Barker, one of the early pioneers of spinal anaesthesia in the UK, observed that the addition of glucose to the solution made for a more reliable effect.4 In the standard scenario, that of a patient placed supine after the injection of a hyperbaric

preparation at the mid-lumbar level, the solution will spread down the slope under the effect of gravity to pool at the lowest point of the thoracic curve, so exposing all nerve roots up to that level to an effective concentration of local anaesthetic. However, if lumbar puncture is performed at the fourth lumbar or the lumbo-sacral interspace the local anaesthetic may be trapped below the lumbar curve, especially if the patient is in the sitting position during injection and maintained in that position for a period thereafter. This results in a block that is restricted to the sacral segments, just as has been described with a spinal catheter that passes caudally.31 Prevention relies on avoiding too low an injection level unless, of course, a deliberate saddle block is intended.

Ineffective drug action

The last possible explanation for a failed spinal is that the solution actually injected reaches the target nerves, but is inactive or ineffective, with a variety of explanations being possible. Identication errors Spinal anaesthetics are supplied in aqueous solution ready for injection and there is no opportunity for confusion in the preparation of the solution itself. However, other optically clear solutions, such as a separate local anaesthetic for skin inltration or analgesic adjuvants, are often used from the same sterile preparation area and the possibility that confusing them may lead to an ineffective block must be considered. Recognition of the possibility of such injection errors has led to the widespread use of syringe labelling in anaesthesia, but this is not as easy within a sterile eld as it is on an anaesthetic work station. Attention to detail is essential, but minimizing the number of ampoules on the block tray (such as using the same local anaesthetic for both skin inltration and spinal) and consistent use of different sizes of syringe for each component of the procedure help considerably. Chemical incompatibility The mixing of two different pharmaceutical preparations also raises the possibility of ineffectiveness as a result of interaction between local anaesthetic and adjuvant. Local anaesthetics seem to be compatible with most of the common opioids, but there has been little formal study of the effects of mixing them, and the situation is even less denitive with other adjuvants such as clonidine, midazolam, and other more extreme substances. Certainly, there are no studies of the stability of three or more substances when mixed together for intrathecal use, a not unknown practice today. Chemical reaction might generate an obvious precipitate, but another possibility is that the pH of the local anaesthetic solution becomes even lower than it was to start with. This would decrease the concentration

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of the un-ionized fraction that is what diffuses into nerve tissue and, unless the solution mixes well with CSF, a decreased effect could result. There is at least one report indicating that the incidence of failure is greater after the addition of a vasoconstrictor solution and this could represent an example of this effect.30 Inactive local anaesthetic solution The older, ester-type local anaesthetics are chemically labile so that heat sterilization and prolonged storage, particularly in aqueous solution, can make them ineffective because of hydrolysis and hence they need very careful handling. Although the more modern amide-linked drugs (e.g. lidocaine, bupivacaine, etc.) are much more stable and can be heat sterilized in solution and then stored for several years without loss of potency, there have been a number of reports attributing failure of spinal anaesthetics to inactive drug.8 16 38 44 Local anaesthetic resistance Very rarely a failed spinal anaesthetic has been attributed to physiological resistance to the actions of local anaesthetic drugs, although the reports tend to the anecdotal.5 23 36 45 A history of repeated failure of dental or other local anaesthetic techniques is accompanied by speculation that the problem is because of a sodiumchannel mutation that renders the drugs ineffective. However, no such mutation has ever been described, and the clinical reports are incomplete, specically failing to consider not only the recognized causes of failure, but also the behaviour of an anxious patient preferring general anaesthesia as an explanation for the resistance. Very detailed investigation would be required for resistance to be accepted as an explanation. As an aside, any patient giving a history of repeated failures with local anaesthesia should be managed by an experienced clinician.

individuals, and anxiety alone can cause much difculty. Further, operating tables are designed for surgical access, not patient comfort; and intra-abdominal stimuli may result in afferent impulses in unblocked parasympathetic and phrenic nerve bres. The more anxious the patient, the greater will be the impact of these factors and the more likely will it be that the patient will fail to cope with the situation and claim that the anaesthetic has not worked properly. Expectation plays a part, and good preoperative patient counselling followed by a supportive approach from the anaesthetist during the operation is important in avoiding such problems, but so is the judicious, and pro-active use of systemic sedative and analgesic drugs. Sufcient sedation to produce drowsiness, or even sleep (with appropriate monitoring), is rarely contra-indicated other than in the obstetric situation, and even there small doses may occasionally be useful.
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Failure of subsequent management

Not all of a patients claims of discomfort, or even pain, during a spinal anaesthetic are the result of an inadequate injection. A properly performed spinal anaesthetic will produce complete somatic, and a major degree of autonomic, nerve block in the lower half of the body unless a specically restricted method is used. However, ensuring that this block occurs is only part of the process because the unaffected components of the nervous system require consideration and management. Specically, this relates to conscious awareness of the clinical setting and of sensations transmitted through unblocked nerves, with both factors possibly making the patient claim that the block has failed. This may not actually be the case, but patient management certainly has failed if such a claim is made when the block is actually as good as it could be. Lying supine and wide awake while undergoing surgery is not a pleasant experience, even for the most sanguine of

Testing the block In recent years, it has become almost mandatory, certainly in the obstetric setting, to test the level of block formally before surgery commences. This apparently sensible precaution may be difcult or impossible to undertake in some patients (for example the demented patient with a fractured neck of femur). Excessive focus on testing can also have a negative impact. Most patients will have some anxiety about the effectiveness of the injection, and this will be increased if testing is started too soon. Conventional practice is to check motor block by testing the ability to lift the legs, followed by testing of sensory block to stimuli such as soft touch, cold, or pin prick, all of which have their proponents. It is advisable to start testing in the lower segments, where onset will be fastest, and work upwards. Proving early on that there is some effect encourages patient condence; testing too soon does the opposite. Even if there is no formal assessment of the level of block, the clinician must be condent that an adequate block has been produced. Establishing that the level of block is appropriate for the projected surgery is often taken to demonstrate that the quality of block is adequate also, but this is not always the case if cold or pin-prick stimuli are used. The observation that the upper block level is a few dermatomes above which innervate the surgical eld (not forgetting the deeper structures) is a good start, but it does not guarantee that the quality of block is sufcient. A covert pinch of the site of the proposed surgical incision may be a better indicator of skin analgesia, and can be reassuring if the block has been slow in onset. Indeed, there is much to be said, particularly when the patient is conscious, for asking the surgeon to do the same with a toothed surgical forceps before incising the skin,10 but surreptitiously and without asking a loaded question such as Does that hurt?! The patient is distracted by conversation and an exchange of glances between surgeon and anaesthetist is all that is needed for surgery to begin.

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Catheter and combined techniques The great majority of spinal anaesthetics involve a single, through needle injection and, as has been noted, this requires some certainty about its effectiveness for surgery. To take advantage of the rapid onset and profound block of spinal anaesthesia, both continuous and combined spinal epidural techniques have been introduced to increase exibility. If the catheters are correctly placed, problems of inadequate spread, quality, and duration of effect can be dealt with although many of the potential technical problems outlined above can still apply. However, both methods require a greater level of skill and experience to use, the insertion of an intrathecal catheter can be surprisingly difcult to achieve in some patients and, as has been mentioned already, can result in the misdirection of the local anaesthetic solution, with the risk of neurotoxicity.34 It is vital to leave no more than 2 3 cm of catheter within the dura to avoid this. In the combined technique, it is common to inject a relatively small volume for the spinal component, so the problems that can result in a proportion not reaching the subarachnoid space are very relevant, but at least the epidural catheter can be used in attempts to rescue the situation.

block, the more likely is the block to be inadequate, so the more detailed this assessment should be. While the onset of spinal anaesthesia is rapid in most patients, it can be slow in some; so, tincture of time should always be allowed.10 However, if most of the expected block has not developed within 15 min, some additional manoeuvre is almost certainly going to be needed. The possibilities, their explanations, and suggested immediate responses are as follows: (1) No block: the wrong solution has been injected, it has been deposited in the wrong place, or it is ineffective. Repeating the procedure or conversion to general anaesthesia are the only option. If, after operation, the patient has signicant pruritus, it is likely that only an opioid was injected. (2) Good block of inadequate cephalad spread: the level of injection was too low, anatomical abnormality has restricted spread, or some injectate has been misplaced. If a hyperbaric solution was used, ex the patients hips and knees and tilt the table head down. This straightens out the lumbar curve, but maintains a cephalad slope and allows any solution trapped in the sacrum to spread further. A variation with the same aim, but perhaps better suited to the obstetric situation, is to turn the patient to the full lateral position with a head down tilt, reversing the side after 2 3 min. If a plain (and usually slightly hypobaric) solution has been used, it may help to sit the patient up, but beware of peripheral pooling of blood. If a spinal catheter injection results in inadequate spread, the response should not be to inject more of the same solution because dose has minimal effect on intrathecal spread.20 Either posture should be manipulated as above, or a different baricity of solution should be tried, or the catheter should be withdrawn before the injection is repeated.31 (3) Good, but unilateral block: this is most likely because of positioning, but it is possible that longitudinal ligaments supporting the cord have blocked spread. If the operation is to be on the anaesthetized limb, then the surgeon should know that the other leg has sensation, and the patient should be reassured and closely monitored. Otherwise, turning the patient onto the unblocked side if a hyperbaric solution was used (or the reverse for plain solutions) may facilitate spread. (4) Patchy block (This term is used to describe a block that appears adequate in extent, but the sensory and motor effects are incomplete.): causes of inadequate block are numerous and include all those discussed above, but the most likely explanation is that the local anaesthetic was at least partially misplaced, or that the dose given was inadequate. If this becomes apparent before surgery starts, the options are to repeat the spinal injection or to use a greater degree of systemic supplementation than was planned, the latter being the

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Management of failure
Failure of a spinal anaesthetic is an event of signicant concern for both patient and anaesthetist even when it is immediately apparent, but it can have serious consequences (clinical and medico-legal) if the problem only becomes evident once surgery has started. If there is any doubt about the nature or duration of the proposed surgery, a method other than a standard spinal anaesthetic should be used. The trainee anaesthetist should avoid over-selling the technique, especially in the early days of unsupervised practice. Promising that all will be achieved by one injection leaves no room for manoeuvre, but offering one injection to reduce pain and a second to ensure unconsciousness does. If a spinal anaesthetic does fail in some way, the management options are limited; so, the rst rule is to expend every effort in prevention.

Prevention is better than cure

Having made the decision to use a spinal anaesthetic, the block should be performed with meticulous attention to detail as has been indicated above. It is impossible to overemphasize this point.

The failed block

The precise management of the failed block will depend on the nature of the inadequacy and the time at which it becomes apparent. Thus, some monitoring of the onset of the block and correct interpretation of the observations are both vital. The slower the onset of either motor or sensory

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only option after skin incision. It may not be necessary to recourse to general anaesthesia, sedation, or analgesic drugs often being sufcient especially when patient anxiety is a major factor. Inltration of the wound and other tissues with local anaesthetic by the surgeon may also be useful in such situations. (5) Inadequate duration: the most likely explanation is that for one of several reasons an inadequate dose of local anaesthetic was delivered to the CSF. Alternatively, lidocaine (intended for skin inltration) was confused for bupivacaine, or the operation has taken longer than expected. Systemic supplementation or inltration of local anaesthetic may tide matters over, but often the only option is to convert to general anaesthesia.

Only some of these problems have actually been described, most being in the category of theoretical possibilities, but such concerns do reinforce the view that every effort must be made to ensure that the rst injection is fully effective.

Recourse to general anaesthesia

There are many ways in which an inadequate block might be rescued, but there is a limit to how much discomfort or distress an individual patient can tolerate, so general anaesthesia must be considered if one or two simple measures have not rectied matters. Common sense and clinical experience are usually the best indicators of exactly when to convert to general anaesthesia, so the unsupervised trainee can be at a disadvantage. However, it is far better to make the decision sooner rather than later and have to deal with a seriously distressed patient. Of course, explaining later why the anticipated technique had not been provided can be difcult. It is another reason why prevention (getting the block right to start with) is the best approach, but it is also a reason for not over-selling the regional approach before operation. If general anaesthesia is induced to supplement a partially effective spinal anaesthetic, any degree of sympathetic nerve block will make hypotension more likely.

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Repeating the block

Where no effect at all has followed the injection it seems reasonable to repeat the procedure, paying close attention to avoiding the potential pitfalls. In all other situations besides total failure, there must be some local anaesthetic in the CSF already, and anxieties relating to several issues have to be taken into account: (1) A restricted block may be because of some factor, probably anatomical, impeding the physical spread of the solution, and it may have exactly the same impact on a second injection, resulting in a high concentration of local anaesthetic at or close to the site of injection. Cauda equina lesions were described after continuous spinal anaesthesia when very restricted spread prompted repeat injections rather than the manipulation of other factors,34 and a similar problem has been described after repeated needle injection.14 19 (2) Repeat injection, especially in response to a poor quality block, may lead to excessive spread,13 so it may be argued that a lower dose should be used to reduce the risk of this possibility. (3) A good quality, but unilateral block, might lead to an attempt to place a second injection into the other side of the theca, but the risk of placing the second dose in the same side must be signicant. (4) Barriers to spread within the subarachnoid space may also affect epidural spread (and vice versa), so an attempt at epidural block may not succeed either. (5) A block of inadequate cephalad spread might be overcome by repeating the injection at a higher level, but should perhaps only be attempted when the indication for a regional technique is considerable. (6) The nal concern, particularly applicable to the last mentioned, but relevant to nearly all situations where a repeat block might be considered, is that the adjacent nerve tissue is already affected by local anaesthetic action so that the risk of direct needle trauma is increased.

Follow-up initiatives
Clinical follow-up As with any anaesthetic complication, the details should be documented fully in the notes, and the patient provided with an apology and a full explanation after operation. Giving the patient a written summary of events for presentation to a future anaesthetist can be very helpful, although care should be taken to prevent medico-legal recourse. Rarely, inadequate spread has been the rst indication of pathology within the vertebral canal. Therefore, it may be appropriate to look for symptoms and signs of neurological disease, and involve a neurologist if there is any suspicion of these being present. It is during the follow-up of a patient in whom no block was obtained, the possibility of local anaesthetic resistance may seem an attractive explanation. As has already been noted, much wider consideration of the possibilities, supported by very detailed investigation, is needed than has been the case in previous reports. Investigating local anaesthetic effectiveness Spinal anaesthesia is usually a simple and effective technique, but failure can occur at any time and in the hands of any clinician, no matter how experienced. However, if the procedure has, apparently, been routine and straightforward concerns can arise that the current supply of local anaesthetic is defective, especially if two or more such failures occur in the same hospital within a short period of time. The preparations which have been most implicated

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are those of hyperbaric bupivacaine ( probably because it is the drug used most commonly at present), with drug from both major suppliers, Abbott38 and AstraZeneca,8 16 44 being involved. In fact, the chemical stability of the amide drugs and modern standards of pharmaceutical manufacture mean that drug inactivity is a most unlikely cause of a failed spinal anaesthetic, but it remains a possibility which at least has to be eliminated. As has been suggested, performing skin inltration with some of the solution intended for the spinal injection should demonstrate that it is effective. If the concern continues the operating theatre, pharmacy and anaesthetic department records should be cross-checked to see whether other practitioners in the hospital have experienced any problems. Similarly, distributors should be able to check whether other hospitals which have been supplied with material from the same batch have reported difculty. If such enquiries reveal that others are using the same material to good effect, the clinician should consider the advice of those two great authorities, Lee and Atkinson, on The spinal that does not take: All experienced workers have encountered this occasionally even though accepted procedure has apparently been followed. Reection, however, usually discloses some aw in technique. In 1907 Alfred E. Barker wrote that for successful spinal analgesia it is necessary to enter the lumbar dural sac effectually with the point of the needle, and to discharge through this, all the contemplated dose of the drug, directly and freely into the cerebrospinal uid, below the termination of the cord (Barker, 1907). Failure to follow the details of this advice is the commonest cause of a poor result.27

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References
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